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Welcome!Food supplementation
programmes for improving the health of socio-
economically disadvantaged children: What's the evidence?You will be placed on hold until the webinar begins. The webinar will begin shortly, please remain on the
line.
What’s the evidence? Kristjansson E., Francis D.K., Liberato S., Benkhalti J.M., Welch V., Batal M., et al. (2015). Food supplementation for improving the physical and psychosocial health of socio‐economically disadvantaged children aged three months to five years. Cochrane Database of Systematic Reviews, 2015(2), Art. No.: CD009924
http://www.healthevidence.org/view-article.aspx?a=28630
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Poll Question #1
How many people are watching today’s session with you?
1.Just me2.2-33.4-54.Over 5
The Health Evidence Team
Maureen Dobbins Scientific Director
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Susannah WatsonProject Coordinator
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1. Saves you time2. Relevant & current evidence 3. Transparent process4. Supports for EIDM available 5. Easy to use
A Model for Evidence-Informed Decision
Making
National Collaborating Centre for Methods and Tools. (revised 2012). A Model for Evidence-Informed Decision-Making in Public Health (Fact Sheet). [http://www.nccmt.ca/pubs/FactSheet_EIDM_EN_WEB.pdf]
Stages in the process of Evidence-Informed Public Health
National Collaborating Centre for Methods and Tools. Evidence-Informed Public Health. [http://www.nccmt.ca/eiph/index-eng.html]
Poll Question #1
Have you heard of PICO(S) before?
1.Yes2.No
Searchable Questions Think “PICOS”
1. Population (situation)
2. Intervention (exposure)
3. Comparison (other group)
4. Outcomes
5. Setting
How often do you use Systematic Reviews to inform a program/services?
A.AlwaysB.OftenC.SometimesD.NeverE.I don’t know what a systematic review is
Poll Question #2
Dr. Elizabeth Kristjansson is an Associate Professor in the School of Psychology at the University of Ottawa.
Elizabeth Kristjansson
ReviewKristjansson E., Francis D.K., Liberato S., Benkhalti J.M., Welch V., Batal M., et al. (2015). Food supplementation for improving the physical and psychosocial health of socio‐economically disadvantaged children aged three months to five years. Cochrane Database of Systematic Reviews, 2015(2), Art. No.: CD009924
Food supplementation programmes improve the health of socio-economically disadvantaged childrenA.Strongly agreeB.AgreeC.NeutralD.DisagreeE.Strongly disagree
16
Poll Question #3
• Undernutrition is the single biggest cause of the global burden of disease
• Every hour, 300 children under 5 die because of undernutrition– Affects growth, current and future health– Undernutrition lowers cognitive performance
and learning in school– Almost half a billion children are at risk of
permanent damage over the next 15 years
The issue
• For infants and young children– Given in day-care,
preschool, feeding centres or delivered to home
• But no comprehensive synthesis of their effectiveness
One intervention: Feeding programs for young children
Objectives• Primary objective:– To assess effectiveness of feeding programs
for improving the health of disadvantaged children aged three months to five years.
– To undertake a process evaluation (including realist review) to understand the mechanisms underlying success or failure.
• Secondary objectives– To assess the potential of such programmes
to reduce socioeconomic inequalities in undernutrition and its consequences.
Our Conceptual model
• 2 reviews integrated into one synthesis– Effectiveness review and process evaluation
(including analysis of subgroups). Set up hypotheses in advance
– Realist review to help untangle mechanisms of action (led by Trish Greenhalgh)
• Followed standard Cochrane and RAMSES guidelines
Methods
Search up to January, 2015. 32,983 records found -> 302 studies retrieved•31 from LMIC, 3 from HIC (1 Aboriginal children)•Study size ranged from 30 to 3166•34 studies met inclusion criteria; 15 were excluded.
• Realist review: all included and 14 Excluded (Close to criteria) studies + 12 theoretical papers
• Characteristics of Included Studies–31 from LMIC, 3 from HIC (1 Aboriginal children)–21 RCTs, 11 CBAs and 2, which used propensity score matching. 26 of these (16 RCTs and 10 CBAs) were in meta-analyses.
Results
• Participants– Ages ranged from
3 to 60 months– Low SES: from
urban slums, poor rural areas, little running water, parents low education
– Study size ranged from 30 to 3166
Characteristics of included studies
• Lower income countries (N = 31)– 9 in Day-cares or feeding centres– 22 Take-home or Home Delivered Rations
• Provision of energy, with nutrients/micronutrients
• Some gave local food (veg, legumes), others gave milk or cereal with milk, others RUTF
• Energy content ranged from 8% to 136% of RDA
The interventions
• Weight – RCTs: (8 studies) 0.12 over six months
or 0.24 over a year– CBAs (7 studies) 0.24 a year
• Height– RCTs: 0.32 cm. more than those who
were not supplemented – CBAs non-significant
Effectiveness: Growth
• WAZ – RCTS (6 studies): 0.11 in
six months– CBA (4): n. s.
• HAZ – RCTs (7): Children who
were fed gained 0.15 more than controls
– CBAS (4) n.s.
• Hemoglobin– Five RCTs with 300
children. Increases in hemoglobin of half a standard deviation (0.49)
Effectiveness: Growth
Forest plot: height
Psychomotor Development• 3 of 5 studies in LMIC; higher scores on
standardized psychomotor tests.– E.g. (SMD = 0.45 (nearly half a standard deviation),
95% C.I. = 0.23 to 1.02).– Another: Supplemented children 6.5 points on
overall DQ. Supplemented + stimulated 13.7 points.–Mental Development.• 2 out of 3 studies in LMIC showed effectiveness
for mental and cognitive development. • E.g. MacKay (supp + stim).
» (SMD = 0.58; 95% C.I. = )
Impact on Psychosocial Development
Preschool feeding works best for
• Children who are lower income/ have poorer nutritional status.
• Generally, grew more relative to controls than those with better nutritional status
• In two, lower income children only grew more IF they were younger.
• But in one study, children in lower SES neighbourhoods did worse; poor environmental conditions.
• Children who are youngerFeeding more effective for younger children for growth, possibly for cognition. BUT still effective for older children, especially for cognition
Preschool feeding works best for
• Children who are younger• Feeding more effective for younger children
for growth, cognition. • In two studies, only effective for younger children
from low SES backgrounds. BUT still effective for older children, especially for cognition
• Possibly, for girls• Mixed evidence. Subgroup analyses showed
no differences but three primary studies showed more effectiveness for girls.
Process AnalysesProbable important factors
• Leakage and substitution within family.• If home delivered, children only benefit from 1/3
of energy of supplement (e.g. 200 of 600 calories)
• Day-care: Children benefit from 2/3 of energy given (e.g. 400 of 600 calories)
• Why? • Home delivered. Parents redistribute supplement
within family.• Day-care or school, child may get somewhat less
at home. • Losses in the supply chain
• Not enough energy given• Programs which
gave more than 30% of RDI tended to be more effective.
• Level of supervision– More leakage with
less supervision. Not enough data from RCTs to fully test hypothesis of low effectiveness
Factors that may be important
• For younger children, seems to be best to have food that is energy dense– Small children can only consume small
volumes• Multiple interventions (e.g. caregiver
nutrition education, child stimulation) tended to be more effective for weight, perhaps for psychomotor development
Other factors
Realist Analysis• Five mechanisms that seem to
characterize successful programs– Physiological mechanisms.– Other mechanisms in the child– General caregiver capacity to learn and
respond– Caregiver capacity to respond to this
intervention– Staff readiness/capability of delivering
intervention
Physiological mechanisms
• Children have clear nutritional needs. Program matches their needs
• Higher % RDI given
• Child has normal appetite– If ill, poor home conditions, less appetite
• Food needs to be palatable• Food should be energy dense– Young children can’t always eat high
volumes
Mechanisms in child Supplement must be given and eaten
consistently
• Caregiver capacity crucial. Things that can compromise capacity– Abject Poverty– Challenging home environment (no space, no
time, lack of clean water)– Low health and nutritional literacy – Need to overcome traditions of favouring
males or of giving everyone the same, regardless of nutritional status • In some studies, part of ration was shared with rest of
family (1 full ration went to child 1/3 of the time)• Must understand need to give most undernourished
child more food
Caregiver capacity in general
• Need a high level of trust, high cultural synergy
• Caregiver has to find that supplement is acceptable, affordable and easy to obtain/prepare– Dropout rate in one study proportional
to distance to feeding centre
Caregiver response to specific intervention
Programme Staff
• Supply chains must be consistent– One study: failure to reach families 20-
30% of time– Another one: 50% of caregivers reported
at least one delivery gap• Caregiver education/capacity
building seems to help• Programme staff must be flexible
• Before implementing programs, work with communities, parents to develop programs and decide on supplements
• Closely supervise distribution and intake
How can we improve effectiveness?
Improving Effectiveness
• Target most undernourished children• Areas with a high proportion of malnutrition
• Give high (at least 40 – 60%) of percent RDA for energy• Consider child’s age
• Foods should be palatable and energy dense
• Fortify the foods
Improving Effectiveness
Provide extra rations for family to reduce sharing
Work with caregivers/ teachers to encourage feeding and stimulation of child
Encourage continued breastfeeding for young children
Supplementation should begin early and continue for several years
Need for more research
• More: • Research on feeding programs and psychosocial
development• Research that studies the effectiveness of single
versus multiple, various % RDI, delivery mechanisms
• Research on impact of feeding on older preschool children
• More research on the question of feeding on gender and income inequity
Review team • Elizabeth
Kristjansson • Damian Francis• Selma Liberato• Maria Benkhalti-
Jandu• Vivian Welch• Beverley Shea• Malek Batal
• Trish Greenhalgh
• Laura Janzen• Mark Petticrew• Eamonn
Noonan• Tamara Radar• George Wells
• 3ie • Global
Development Network
Thank you!
Funding and Support
Thank you!
Food supplementation programmes improve the health of socio-economically disadvantaged childrenA.Strongly agreeB.AgreeC.NeutralD.DisagreeE.Strongly disagree
Poll Question #4
Poll Question #5Do you agree with the findings of this review?A.Strongly agreeB.AgreeC.NeutralD.DisagreeE.Strongly disagree
Questions?
A Model for Evidence-Informed Decision
Making
National Collaborating Centre for Methods and Tools. (revised 2012). A Model for Evidence-Informed Decision-Making in Public Health (Fact Sheet). [http://www.nccmt.ca/pubs/FactSheet_EIDM_EN_WEB.pdf]
51
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